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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 198602162
Report Date: 02/08/2023
Date Signed: 02/08/2023 05:13:49 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/31/2023 and conducted by Evaluator Martessa Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230131083902
FACILITY NAME:SANTA FE HOME CARE IIIFACILITY NUMBER:
198602162
ADMINISTRATOR:ASIS, VIRGINIAFACILITY TYPE:
740
ADDRESS:23223 PRYOR PLACETELEPHONE:
(310) 989-1941
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY:6CENSUS: 3DATE:
02/08/2023
UNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Virginia AsisTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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9
Facility staff are not taking proper measures to keep facility free of roaches.
Facility staff are not ensuring facility is kept clean.
Facility staff are not meeting residents' dietary needs.
INVESTIGATION FINDINGS:
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13
On 02/8/23 Licensing Program Analyst (LPA) Martessa Brown initiated a complaint investigation for the allegations listed above. LPA conducted Covid-19 risk assessment before entering the facility and there were no positive Covid-19 cases. LPA explained the purpose of today’s complaint investigation was to gather information. LPA Brown conducted visit with Marley Andrada-Caregiver and later joined by Administrator Virginia Asis.
The investigations consisted of the following: On 2/8/23 LPA toured the entire facility. LPA requested staff roster & resident roster, pest control invoices for the last 3 months, reviewed and requested residents R1-R4 most recent physicians’ reports, appraisals & needs and service, emergency contacts and admission agreements. LPA conducted interview with residents Resident (R2) and attempted to interview (R3-R4). LPA conducted interviews staff (S1-S3).

Investigation revealed:
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 11-AS-20230131083902
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SANTA FE HOME CARE III
FACILITY NUMBER: 198602162
VISIT DATE: 02/08/2023
NARRATIVE
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Allegation: Facility staff are not taking proper measures to keep facility free of roaches.

It is alleged that facility has a roach infestation and not taking proper measures.

On 2/8/23, LPA toured the facility at 10:05 AM and observed roaches on the office desk, kitchen counters, inside the refrigerator, bathrooms, inside facility files, residents R2 and R3 bedrooms floors and inside drawers. LPA conducted interview with R2 stated they been having roaches for a while and will also kill them while sleeping in bed. LPA attempted to interview residents R3-R4 were unable to answer questions. LPA conducted interviews with staff S1-S3, all staff stated they have been having problems with roaches in the facility for a while. Staff stated they will spray the roaches and pest control was there last Friday. Based on evidence and interviews the above allegation is substantiated.

Allegation: Facility staff are not ensuring facility is kept clean.

It is alleged that facility is not clean due to clutter contributing to roach problem.

On 2/8/23, LPA toured residents R2 and R3 bedrooms. LPA observed at 10:30 AM in bedroom #2 window seal had dead bugs and on the floor. Observed R2’s food tray had a broken piece and was dirty. Bedroom closet was clutter with boxes and bags. The wall on the side of R2’s bed had stains. Bedroom #3 had dead roaches in the bathroom shower and on the floor. Interview R2 stated facility will clean floors every day but walls are dirty from smashing bugs. Interviews with S1-S3 stated facility is clean every day in the mornings and at nights. Staff stated facility is cleaned using cleaning supplies. Based on evidence and interviews the above allegation is substantiated.

Allegation: Facility staff are not meeting residents' dietary needs.

it is alleged that facility is not serving vegetables or that pancakes are served for dinner.

(Next Page)

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Elizabeth Ceniceros
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 11-AS-20230131083902
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SANTA FE HOME CARE III
FACILITY NUMBER: 198602162
VISIT DATE: 02/08/2023
NARRATIVE
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On 2/28/22, LPA observed at 10:05 AM refrigerator had spoiled bacon and lunch meat. There was also old vegetables and brown lettuce. LPA conducted interview with R2, stated was not on any type of diet restriction. Resident stated buys own breakfast and lunch sometimes. Resident stated was served a jelly sandwich and water for dinner one time. Resident also stated food times will vary and some residents will eat before each other. Interviews with staff S1-S3, stated residents are provided with breakfasts, lunch, and dinner that consist of oatmeal, fruit, spaghetti, meats, vegetables, and rice. Staff stated there is no residents with diet restrictions. Administrator stated groceries are purchased on Thursday.

On 10/10/23 LPA/RA Ceniceros conducted a collateral visit as a follow up and met with Staff #3: Norma Apresto, House Manager. LPA/RA toured the facility's kitchen and observed perishable and non-perishable food supply. LPA/RA reviewed the facility's monthly menu which consisted of meats (bacon, beef, chicken), fish, pasta, fruits, breads, vegetables, cheese, milk, eggs, potatoes, oatmeal, cereal, french toast, soups, and juices served for breakfast, lunch, and dinner. During this visit, LPA/RA arrived during residents' meal time (lunch) approximately 12:00 noon and observed the residents meal (photo): salad (lettuce, carrots, tomatoes, dressing), chicken teriyaki, white rice, sliced cantaloupe, and fruit juice.

On 10/18/23, LPA/RA Ceniceros conducted a subsequent visit to deliver the "amended" report. LPA/RA spoke to Administrator Virginia Asis (via telephone) who was out of town. Based on the evidence and interviews, the above allegation is substantiated.

Based on LPA Martessa Brown's interviews and records review on 02/08/23 and LPA/RA Elizabeth Ceniceros' record review and observation (on 10/11/23) and subsequent visit (on 10/18/23) the preponderance of evidence standard is met; and, the above-mentioned allegation found to be substantiated.

According to the California Code of Regulations, Title 22, Division 6, Chapter 8 the facility was cited on 02/08/23 and the Plan of Correction cleared on 02/10/23.

An exit interview was conducted and a copy of the two "amended" (LIC 9099C) pages were provided to Staff #4 (S4: Purificacion Olaco, Caregiver).

SUPERVISORS NAME: Janae Hammond
LICENSING EVALUATOR NAME: Elizabeth Ceniceros
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 11-AS-20230131083902
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SANTA FE HOME CARE III
FACILITY NUMBER: 198602162
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2023
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met as evidence by:
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Licensee will have a exterminator to come to facility to clear bug infestation throughout the entire facility. Licensee will come up with a plan on how they will ensure facility will be cleared from bugs. POC is due by 2/10/23
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At 10:05 LPA observed roaches throughout the facility in the kitchen, bedrooms and bathrooms.

This is a potential health and safety risk to clients in care
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Licensee will clean the facility to clear bug infestation throughout the entire facility. Licensee will come up with a plan on how they will ensure facility will be cleared from bugs. POC is due by 2/10/23
Type B
02/10/2023
Section Cited
CCR
87303(a)
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2
3
4
5
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7
87303 Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met as evidence by:
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Licensee will clean the entire facility and remove dead bugs. R2 food tray will need to be replaced . Refrigerator will need to be clean. POC is due by 2/10/23.
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At 10:35 AM LPA observed dead bugs throughout the facility window seals, refrigerator, floors, bathrooms. Bedroom #2 closet had clutter on the floor and food tray was dirty and broken.

This is a potential health and safety risk to clients in care
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9
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 11-AS-20230131083902
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: SANTA FE HOME CARE III
FACILITY NUMBER: 198602162
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/10/2023
Section Cited
CCR
8755(b)(28)
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87555
General Food Service Requirements
(b) The following food service requirements shall apply:
(28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery.
This requirement was not met as evidence by:
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Licensee will provide a plan and train staff on how they will ensure food is not expired and spoiled by POC due date.
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LPA observed expired lunch meat dated 1-30-23. Spoiled bacon and old vegetables and discolored lettuce.

this is a potential health and safety risk to resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
LIC9099 (FAS) - (06/04)
Page: 7 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/31/2023 and conducted by Evaluator Martessa Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 11-AS-20230131083902

FACILITY NAME:SANTA FE HOME CARE IIIFACILITY NUMBER:
198602162
ADMINISTRATOR:ASIS, VIRGINIAFACILITY TYPE:
740
ADDRESS:23223 PRYOR PLACETELEPHONE:
(310) 989-1941
CITY:HARBOR CITYSTATE: CAZIP CODE:
90710
CAPACITY:6CENSUS: 3DATE:
02/08/2023
UNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Virginia AsisTIME COMPLETED:
05:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Ramp leading up to the house presents a tripping hazard.
INVESTIGATION FINDINGS:
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2
3
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On 02/8/23 Licensing Program Analyst (LPA) Martessa Brown initiated a complaint investigation for the allegations listed above. LPA conducted Covid-19 risk assessment before entering the facility and there were no positive Covid-19 cases. LPA explained the purpose of today’s complaint investigation was to gather information. LPA Brown conducted visit with Marley Andrada-Caregiver and later joined by Administrator Virginia Asis.
The investigations consisted of the following: On 2/8/23 LPA toured the entire facility. LPA requested staff roster & resident roster, pest control invoices for the last 3 months, reviewed and requested residents R1-R4 most recent physicians’ reports, appraisals & needs and service, emergency contacts and admission agreements. LPA conducted interview with residents Resident (R2) and attempted to interview (R3-R4). LPA conducted interviews staff (S1-S3).

Investigation revealed:
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 11-AS-20230131083902
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME: SANTA FE HOME CARE III
FACILITY NUMBER: 198602162
VISIT DATE: 02/08/2023
NARRATIVE
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Allegation: Ramp leading up to the house presents a tripping hazard.

It is alleged that ramp leading into the home is a tripping hazard.

On 2/8/23, LPA toured the facility and observed the ramp leading to the home. LPA did not observed ramp to be a tripping hazard. LPA interviewed R2 stated ramp was there for a year and makes it easier to leave the facility. LPA conducted interviews with staff S1-S3, stated ramp has been there for a year and there has not been any concerns with ramp leading into the home. The above allegation is unsubstantiated.

Exit interview was conducted with Marley Andrada.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Martessa Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 7